Why Do Orthodontists Get So Little Training In TMD/Occlusion?

This past week in Orthopreneurs included a great thread about a patient who presented to an orthodontic office with occlusal issues related to their use of an NTI appliance. As the discussion evolved, there was a back and forth related to occlusion, TMD, splints and the management of patient symptoms/joint health before, during and after orthodontic treatment.

I was lucky enough to spend 3 years in a TMD/Occlusion program that was hosted at the University of Washington from 1998-2001. My teacher, the late Dr. Gerard Schultz, was the same man who taught Spear and Kois their occlusal concepts, and was a brilliant, patient man. We studied the literature related to occlusion and its effect on the joints and muscles of the “stomatognathic sytstem” (the teeth, jaws and muscles), otherwise known in lay terms as “gnathology”. Yeah there are some out there who like to poke fun at gnathology as “the study of how articulators work” but that’s a silly comment made by those who never took the time to learn what it was really all about. In my three years of study, I did learn two overarching principles of gnathology:

1. The occlusion can have a significant impact on the muscles of mastication
2. We best pay attention to these principles because while the overwhelming majority of our patients can adapt to almost any type of occlusion, when those patients who can’t adapt show up (and we can’t predict who they will be) we need to know what to do

So, when I got to orthodontic residency and was told to “forget everything you learned about occlusion as a restorative dentist” I was expecting some amazing curriculum on occlusion. I was surpassed to find that the overwhelming of “good” orthodontists never once went through a formalized curriculum that taught them about the impact of the occlusion on the muscles, how to properly evaluate the TMJ, what to do with any signs or symptoms of pathology of the tmj, how to differentiate between myofascial pain and joint issues and how to fabricate splints/appliances to assist patients.

You’ll hear the occasional reference to the Piper classification, or some splint they learned about, but unless someone took the Roth course, if you dive into even the most basic of discussions related to occlusal interference and muscle issues, there isn’t much of a repartee. Sure, many have been taught some splint therapy basics in their programs, but if I were to ask them how comfortable they would be doing even the most basic of procedures, a full mouth occlusal equilibration, most would question the value and few would know where to begin.

Why is it that orthodontists, the masters of occlusion, haven’t been given a deep dive into TMD/splints, equilibration, etc? I have a few thoughts about possible reasons.

1. Their faculty never learned and therefore, can’t teach it.
2. There was a real “battle” in orthodontics at one point between those who were “gnathologists” and those who weren’t and there is a lingering belligerence to not teach that “garbage”.
3. There’s only so much time in a student’s ortho residency and teaching this would take away from their ability to teach what is “vital” to everyday ortho practice.
4. There are a ton of great resources out there where one can learn occlusion and function/TMD if one wants to after graduation. Places like Spear or Kois have curriculums on this stuff.
   

I can’t tell you which one is true, but I can say that learning about how to do a proper TMJ exam, how to do a full occlusal equilibration, basic splint therapy and understanding occlusion has helped me more times than I can count. It’s allows me to “stabilize” patients before ortho, help people lead normal lives (myofascial pain can drive people bananas), know when to refer to my TMJ specialist, have cogent discussions on occlusion with my referring doctors and understand the affect my treatment decisions have on the entire stomatognathic system.

So many GPs have “drunk the Kool Aid” on silly, unsupported fixes to TMJ issues and we are going to see their patients to help put the pieces back together after it all falls apart.

You may be intimidated by your lack of knowledge on the subject or you might be an expert or even someone who thinks this is all ridiculous overkill, but go find the “best” orthodontist in your town. You know, the one who every single ortho in the region looks up to as the “patriarch” of the region. I’d be willing to bet that they were Roth trained or have an “occlusal approach” to their treatment.

If that’s the case, why isn’t this trickling down into our residency programs?

As always, wishing you the best!!!